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The extant rationale for mandated therapy during psychotherapy and counselling training: a critical interpretive synthesis

Citation: Edwards, Jane 2018, The extant rationale for mandated therapy during psychotherapy and counselling training: a critical interpretive synthesis, British journal of guidance & counselling, vol. 46, no. 5, pp. 515-530.

DOI: 10.1080/03069885.2017.1334110

©2017, Crown Copyright in the Commonwealth of Australia

Reproduced by Deakin University under the terms of the Creative Commons Attribution Non-Commercial No-Derivatives Licence

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The extant rationale for mandated therapy during psychotherapyand counselling training: a critical interpretive synthesisJane Edwards

School of Health & Social Development, Deakin University, Victoria, Australia

ABSTRACTAttending personal therapy sessions is a requirement in many counsellingand psychotherapy trainings worldwide. More research is needed toestablish why the requirement is essential and what it is intended toachieve. This study focused on the question, what is the rationale formandated self-development requirements in therapy trainings? From aselective literature search, 19 highly relevant papers were found whichformed a sampling frame. The papers included qualitative studies, mixedmethod reports, review and opinion papers. Research participants acrossall reports included therapy and psychiatry trainees (N = 1134), andcurrent therapy practitioners (N = 194) totalling 1328 participants. Thepapers were analysed using Critical Interpretive Synthesis method todevise a synthesising statement. The analysis resulted in a synthesisingstatement about the rationale for personal psychotherapy duringtraining, and the stated risks of this requirement as reflected in thematerials consulted. A strong coherent rationale exists for therecommendation that trainee therapists undertake personalpsychotherapy. However, the risks of mandating this requirementpresent multiple challenges, and the evidence for the intendedoutcomes of personal psychotherapy undertaken during training is weak.

ARTICLE HISTORYReceived 13 December 2016Revised 25 February 2017Accepted 18 May 2017

KEYWORDSCareer development; careereducation; psychotherapy

Introduction

Attending personal therapy sessions is a requirement in many counselling and psychotherapy train-ings worldwide. However, there is no accepted agreement on whether this should be required for alltrainee therapists. For example, The British Psychological Society (BPS) does not require trainees inthe Clinical Doctorate to attend personal therapy, but students in BPS accredited counselling psychol-ogy trainings must attend 40 hours of personal therapy. In Greece, all counselling students mustattend 40 hours of personal therapy. The rationale provided is that,

… besides getting to know themselves better, it [personal therapy] will sensitize them to the feelings, thoughtsand expectations a client might experience during the therapeutic process. (Malikiosi-Loizos, 2013)

For the British Association for Counselling and Psychotherapy experience of personal therapy is not arequirement to be qualified to practice, but it can be used to meet criteria for accreditation as a thera-pist including as a contributor to documented ongoing professional development requirements.

Attending personal psychotherapy during training is conceptualised as providing opportunitiesfor students to learn about use of the self within therapeutic work. Students have the opportunityin personal therapy to develop and refine their capacity to use insight. Therapy trainees learn to

© 2017 Crown Copyright in the Commonwealth of Australia. Published by Informa UK Limited, trading as Taylor & Francis GroupThis is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided theoriginal work is properly cited, and is not altered, transformed, or built upon in any way.

CONTACT Jane Edwards jane.edwards@deakin.edu.au

BRITISH JOURNAL OF GUIDANCE & COUNSELLING2018, VOL. 46, NO. 5, 515–530https://doi.org/10.1080/03069885.2017.1334110

manage their experiences in interaction with the client through employing what has been describedas a reflective stance (Rizq & Target, 2008), or engaging reflective function (Ensink et al., 2013).

The ability to both discern one’s own reactions and feelings and to use these to reflect upon theinterpersonal dynamics occurring is a key element in expert practice within interpersonal psychody-namic therapy (Bateman & Fonagy, 2011). In a discussion of mandatory individual psychotherapyduring training Kumari identified that:

A heightened awareness of the self is seen as a fundamental aspect of the majority of approaches to therapy,particularly those that aim to help clients change their behaviour or cognitive processes… Adequate self-aware-ness is also essential to ensure that the therapist does not become completely overwhelmed by seeing clientswho are often extremely distressed. (2011, p. 213)

In an empirical study of 25 therapists who treated 1001 patients it was shown that reflective functionof the therapist and the therapist’s attachment history had mutual impact. The researchers found that‘ … [s]ecure attachment compensated somewhat for low reflective functioning and high reflectivefunctioning compensated for insecure attachment’ (Cologon, Schweitzer, King, & Nolte, 2017, p. 1).Individual personal therapy during training is intended to achieve gains in the use of reflective func-tion but this learning is impacted by the students’ attachment style (Rizq & Target, 2010a).

Self-learning as a requirement of therapy training

Enhancing insight is a goal of personal therapy (Lacewing, 2014). It is described in psychotherapy andcounselling literature as a way of perceiving what is happening in therapy that is distinct from anintellectual understanding or theoretical interpretation (e.g. Casement, 1985; Jørgensen, 2004). AsJørgensen has indicated:

Part of what the good therapist has to offer is different perspectives on the self and reality—perspectives thatopen up new forms of behavior and new ways of relating to others… Classic psychodynamic theory has concep-tualized parts of this process in terms of the patient’s gaining insight into her history and intrapsychic functionand concomitantly developing the observing ego. (2004, p. 529)

One of the claims of psychotherapy is that the early attachment relationship is re-activated(Schore, 2001). By exploring their attachment history the client has the opportunity to address andresolve unsatisfactory internalised aspects of the first relationship. There is evidence to indicatethat rates of insecure attachment are similar among cohorts of therapy trainees and the generalpopulation (Rizq, 2011). It is therefore possible to predict that, for at least some insecurely attachedtrainees attending psychotherapy, painful, distressing and discomforting feelings could be experi-enced for the duration of the work.

A key finding from research about trainee experiences of mandated personal therapy is the pro-blematic cost. An analysis of interviews with eight participants in a counselling psychology trainingpointed to the paradox that the stress of the cost and burden of time to participate in therapy fortrainees was likely to militate its effectiveness (Kumari, 2011). In one study there were multiple ‘reac-tions to the cost including “a worry”, “stressful”, “a burden”, and “a nightmare”’ (Moller, Timms, & Ali-lovic, 2009, p. 378).

Research with practicing professionals reflecting on their personal therapy during training or as acomplement to practice have reported mixed experiences. For example, a survey of 95 senior psy-chiatric trainees across Australia and New Zealand in 2003 found only 22% of respondents consideredpersonal therapy essential (Foulkes, 2003). In a survey of 48 psychiatric trainees in London, one thirdof respondents had attended personal psychotherapy and reported it as beneficial, and the majorityof the remainder indicated they would consider attending psychotherapy (Sathanandan & Bull, 2013).Of 25 psychotherapy registrars in the UK who responded to a survey (Macaskill & Macaskill, 1992), 15reported negative effects from their therapy. The main negative effects for these respondents werepsychological distress (29%) and marital or family stress (13%).

In a study of 400 psychiatry residents in Canada, self-reports about the value of psychotherapyimpacted confidence of trainees in applying professional skills.

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… residents who had received personal therapy rated themselves as better able to understand what happensmoment by moment during therapy sessions, detect and deal with patients’ emotional reactions, and make con-structive use of their personal reactions to patients. (Hadjipavlou, Halli, Hernandez, & Ogrodniczuk, 2016, p. 35)

It has been proposed that the requirement for mandated personal therapy during training forpeople who are well is ‘neither intellectually nor ethically coherent’ (Atkinson, 2006). An alternativeview has suggested that:

Stated in ethical terms, the debate concerns the proposition that undertaking personal psychotherapy whiletraining to be a psychotherapist is ethically responsible because it maximizes therapeutic functioning while mini-mizing the possibility of harming clients or acting in ways that are not in their best interests. (Ivey, 2014, p. 92)

In the contemporary student-as-customer ethos increasingly permeating the higher educationsector (Lynch, 2010) if students do not appreciate or like a certain aspect of a course, or cannotsee the benefit to them, a strong evidence-based rationale is needed to support its retention. Notall trainees reflecting on their experiences in learning to become a therapist report personaltherapy as essential, but as Heathcote has described,

…what is needed is for trainers and supervisors to help trainees to develop their own understanding regardingthe importance and significance of commitment to their in-depth psychotherapy journey. Experience suggeststhat as trainees develop this understanding, continued commitment to their own growth and psychotherapyis a natural outcome. (2009, p. 245)

Von Haenisch (2011) noted that participants’ later reflections on their experience of mandatorypsychotherapy in training reported in her study were similar to those of Rothery (1992) almosttwo decades prior. Both studies reported that with hindsight the participants were positive aboutthe benefits of individual psychotherapy. However, some respondents had felt unwilling toengage and use the opportunity at the time of training (Von Haenisch, 2011).

A study of 37 trainees in three counselling and psychology courses across the UK found thatrespondents believed that ‘ …making personal therapy a requirement of training made it potentiallyless effective, and that the requirement assumed that the trainee needed personal therapy’ (Moller,et al., 2009, p. 380). However, it was concluded that ‘there are always personal issues to be dealt with,thus there is a tension between what might be termed the “don’t need it/everyone needs it” pos-itions’ (p. 380).

Reflexivity: the stance of the researcher

This research was prompted by concerns raised by students and management in a course I previouslyled about the role and function of personal therapy for students. I have elsewhere stated how,

…without better evidence and theoretical support as to the need for a personal development component intherapy training, and without a pedagogical rationale for its implementation, it is difficult to progress a convincingargument to managers within the customer focussed university context as to a. why individual psychotherapy isrequired, and b. if it is required, why students should pay for it. (Edwards, 2013, p. 221)

The requirement to attend personal psychotherapy can be difficult to justify within a higher edu-cation institution because pedagogical clarity over-rides the way we have always done thingsargument.

A student’s feeling of being overwhelmed can sometimes be linked to the materials taught andrequired to be considered in such programmes. Some examples include child sexual abuse,trauma and stressful and potentially traumatising life events such as divorce, death and bereavement.Students may be additionally stressed by the emerging realisation of the unmet needs of theircurrent and future clients (Edwards, 2013). Personal therapy is intended to offer a way to processand integrate some of these difficulties, within a confidential and safe space provided for theworking through of issues as they arise.

However, although I hold a positive view as to the value of personal therapy during training Imust admit to concern about the implications of endorsing a personal psychotherapy requirement

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for students who are not aligned with the dominant culture, for example in relation to race or sexu-ality. The sinewy, embedded nature of Eurocentrism across therapy work, social sciences andresearch findings underpin psychotherapy practice (Joseph, 2015). The symbolic violence of the mis-recognition of the client’s culture and sensitivity to their world view is increasingly considered a siteneeding remediation within professional associations and training courses (e.g. Moon, 2011). Thishas tempered my previously more strongly held view about the value of requiring personaltherapy in training.

There are multiple examples in the literature that give cause for concern that some therapistshave so little understanding of the impact of their behaviour on the client (e.g. Trimboli, Keenan,& Marshall, 2016). Students are potentially seeking out and paying for professional support frompeople who could behave as per these problematic examples which, as the paper’s title worryinglyindicates, are considered common. These point to potential serious dangers to trainees, and in thewider therapy field. This additional risk is challenging for the course team to manage. Of course thecompetent practitioner uses self-reflection and the supervisory process to consider mistakes andrectify them, but it is not clear this happens in every situation. How would the student learn whatto do should such a mistake occur in their own behaviour when providing therapeutic support toanother?

It is my view that a culturally competent therapist not associated with the course can play animportant role in listening carefully and empathetically to the student. They can help the studentsto consider other points of view if they experience upset during the course. Attending therapy isone way for the student to be supported to manage their trajectory through the demands of anintensive therapy course. Individual therapy can help students develop greater knowledge andrespect for the therapeutic process; not as something one superior expert provides to a vulnerableand needy person but rather a process which aims to build capacity through mutuality, and a trustingpartnership.

Aim of the research

This study aimed to critically review the current research and literature to further explicate the under-lying reasoning for the inclusion of self-development in therapy trainings. The guiding question waswhat is the rationale for mandated self-development requirements in therapy trainings? Rather thantreating the topic as controversial, the paper engaged the ways in which this issue is presented inthe relevant research literature. By focusing on how the rationale for inclusion of personal therapyin training is positioned, it was intended to highlight hidden assumptions, and to reveal commonareas of agreement and disagreement.

Method

Critical interpretative synthesis (CIS) was chosen to conduct this meta-synthesis. CIS offers a processby which new findings can be gleaned from a large number of complex, diverse sources. The fluidityand flexibility of the method was additionally attractive (Dixon-Woods et al., 2006).

CIS method was originally founded as a way to conduct a literature-based study to better under-stand the complexity of issues in access to healthcare (Dixon-Woods et al., 2006). Critical is used in thedescription of the method to reflect the expectation that the researcher will undertake the reviewwith ‘emphasis not only on summary of data reported in the literature but also on a more fundamen-tal critique, which may involve questioning taken-for-granted assumptions’ (Dixon-Woods et al.,2006). The goals of applying CIS method can be multiple. However, usually the intent is to create‘a transformation of the underlying evidence into a new conceptual form’ (Dixon-Woods et al.,2006). The reviewer is encouraged to take ‘a critical and reflexive approach to the literature, includingconsideration of contradictions and flaws in evidence and theory’ (Dixon-Woods et al., 2006). Theresearcher is expected to identify and interrogate underlying assumptions in their own values and

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beliefs as well as those represented in the materials included in the review (Dixon-Woods et al., 2006);including normative assumptions, and societal and cultural expectation implicit in the study’s use ofterms, and reference to participants, services and others.

Literature search

Nineteen papers were found that met the inclusion criteria (see below). The CIS literature searchprocess aims to provide an adequate number of relevant papers to achieve what is described asthe sampling frame (Dixon-Woods et al., 2006). An initial search was conducted using EBSCO host(including Medline and Cinahl), and PubMed. Keywords used in the search included ‘self-develop-ment’ and ‘psychotherapy training’, ‘counselling’, ‘counsel*’, ‘training’ and ‘self-development’. Afurther PubMed search with the MeSH term counselling/education was undertaken. Similarly tothe experience of Dixon-Woods et al. (2006), a large number of papers were found (N = 1189)most of which had little or no relevance to the topic.

Useful results were more successfully found by hand-searching the reference lists of the first rel-evant papers found. Using the PubMed similar articles function also revealed further papers. Somepublisher databases through which certain papers were accessed provided linked articles in sidemenus which were read and, if relevant, included. Additionally, using the citations function ingoogle scholar revealed further studies citing the studies already in the reference list. The onlyquality criteria applied was that the research was published in a peer reviewed journal. As thepurpose of the research was to explore the underpinning rationale for requiring therapy attendanceduring training as a therapist, it was important that the representation of the issues had been scru-tinised by peers.

Inclusion criteria – Only papers published in English were included. Papers which examinedtherapy students’ self-development during training by active methods designed to facilitate self-development such as individual personal psychotherapy, rather than tacit processes, were included.Papers which included comparisons between students where personal psychotherapy was not man-dated were also included.

Exclusion criteria – papers were excluded which referred to students who were not training inpsychological therapies, for example nursing students, or were not primarily verbal psychotherapies,for example creative arts therapy reports. Papers which concerned the experience of therapy prac-titioners as therapy clients were also excluded. Studies or reports of self-development experientialprocesses facilitated by a member of the course team were excluded, and also papers where itwas not specified who facilitated the experiential work. Papers researching or providing reviews ofthe role of group work processes for trainees were also not included. There were also some briefopinion reports for or against mandated personal therapy that were excluded.

The CIS process

The process of completing the CIS involved (1) Identifying an adequate pool of relevant abstracts, (2)Selecting papers from these that were the most relevant and adequately in-depth with regardsexploration of the topic of self-development in therapy training qualitatively or empirically, (3)Reviewing the papers recording the method, the main rationale exposed, and any critical statements,and (4) Undertaking and reporting the synthesis.

No specific date range was used in conducting the search but one paper prior to 1980 wasremoved. After exclusion of duplicates, 19 papers were found that met the criteria for inclusion pub-lished between 1996 and 2016. A majority of the papers were published during or after 2011. At alater stage a few further relevant papers were found. These were cited but not included in the analysisas the sample was considered adequate, the analysis had progressed substantively and they did notadd any further unique rationale statements or findings.

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The included papers fell broadly into three types. (1) Literature-based reviews of the topic, (2)Surveys or interviews with current practitioners reflecting on their personal therapy experiencesduring training and (3) Survey- or interview-based qualitative studies with current trainees under-going personal therapy. The participants included therapy and psychiatry trainees (N = 1134), andcurrent therapy practitioners (N = 194) totalling 1328 research participants.

Analysis of the materials

Each paper was read carefully and examined for instances of descriptions or statements that provideda rationale for mandated self-development in therapy training. The papers were summarised in termsof participants, method, rationale for mandated personal therapy and any critical or alternative per-spectives or cautions stated explicitly or tacitly in the paper (see Table 1). Each of the rationale state-ments was compared. Where rationales included more than one rationalising statement these wereseparated.

Initially it was intended to seek out differences between traditions of therapy. Given the smallnumber of papers found, and the contrary actions and opinions about personal psychotherapyeven within some aligned traditions it was decided to focus on the papers without reference tothe psychological tradition of the training. Not all papers referred to mandated personal psychother-apy. It was sometimes not clear whether personal therapy was a course requirement, a requirementof the professional association or optional. Therefore the mandated aspect was only loosely referredto during the analysis.

The process of analysis involved moving back and forth between the synthesising statements andthe original paper, comparing concepts between papers, and describing in detail the rationales thatappeared in the paper, or were able to be derived from the points of view about self-development intherapy training. Each of these rationale statements were copied in full based on the text in the paper(see Table 1). They were then broken down into around 60 meaning units (see Table 2) with a singlerationale for the benefit of personal psychotherapy during training identified in each of these; forexample, ‘increased empathy for the client role’. General enthusiastic statements about potentialgains in undertaking personal psychotherapy during training which did not point to any specific out-comes were removed. These meaning units – or first order statements – were then compared forsimilarities and grouped (see Table 3).

The second order statements resulted in the following rationale – Personal psychotherapyduring therapy training is required because it can: enhance the trainee’s capacity for empathytowards the client; enhance the trainee’s knowledge of techniques and capacities for use in practice;reduce the likelihood of future harm towards clients; contribute to the trainee’s personal growth;help the trainee gain deeper insight into therapeutic processes; afford wider implications andbenefits.

Critical statements from the literature were then examined using a similar process as for the ration-ale above (see Table 4). This resulted in the following critical statements – Personal psychotherapyduring training is problematic because: it is disputed whether personal psychotherapy is warrantedfor well, untroubled trainees; other self-development pathways apart from mandated personal psy-chotherapy should be considered; although there is some evidence for the benefit of personal psychother-apy, claims for the benefits of personal psychotherapy over-reach the existing evidence; trainees’resistance to engaging therapy is not dealt with optimally; personal psychotherapy during training ishard and expensive and can disrupt effective work with clients; the rationale for personal psychotherapyis not adequately clear.

Refutational synthesis

The refutational synthesis within CIS is focused on the main points of disagreement evident in theresearch (Dixon-Woods et al., 2006). These are interrogated further through reflecting on

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Table 1. Summary of papers included in the critical interpretive synthesis.

Paper Method Participants Rationale – summary Critical concepts identified by the author/s

1. Edwards (2013) Literature review N/A Personal therapy undertaken during training isa way to (1) Experience what the clientexperiences and (2) To learn techniquesdirectly through modelling the therapist’sactions.

Psychotherapy training without a personaltherapy component might be possiblewhere a person has spent adequate timeaddressing issues through personalpsychotherapy in the past.

2. Hadjipavlou, Halli,Hernandez,andOgrodniczuk(2016)

Questionnaire N = 400 psychiatry trainees in Canada Personal therapy consistently has been shownto be one of the most highly ranked positiveinfluences that psychotherapists’ indicateinfluences their professional development

… residents who had received personaltherapy rated themselves as better able tounderstand what happens moment bymoment during therapy sessions, detect anddeal with patients’ emotional reactions, andmake constructive use of their personalreactions to patients

… personal therapy may interfere:with the ability of inexperienced trainees toprovide psychotherapy

…with marital harmonyAnd may aggravate normal professionaldevelopment crises

3. Wigg, Cushway,and Neal (2011)

Systematic literature review –six exploratory studies andfour review studies included

N/A Personal reflections can be seen as thoseprocesses which encourage personal growthand development to take place, includinghow personal issues impact on practice, whatit is like to be a client, knowing one’sboundaries and intense self-experiences inPT. This theme also includes personalreflexivity, insight and acceptance of the self.

… assumption that therapists’ self-reportedimproved skills and well-being impactpositively on clients… there is only indirectevidence of increased empathy andtherapist warmth to support thissuggestion.

4. Ivey and Waldeck(2014)

Qualitative interviews Nine trainee therapists studying atgraduate level who were at internshipstage

Personal therapy helps students with difficultaspects of their training. Being in personaltherapy specifically helps with understandingof the processes and dynamics ofpsychotherapy, specifically experiences oftransference, interpretation, termination, andtherapy techniques…

Trainees start out with the idea that having toattend therapy is a personal attack

5. Kumari (2011) Qualitative interviews –analysed via IPA

Eight counselling psychology trainees –IPA

Enhancing understanding of client role.… therapists who undertake personaltreatment are likely to make major gains,both with their clinical work and in theirpersonal lives, although this is sometimesassociated with substantial emotionaldistress.

… trainee therapists’ skills becomenegatively affected when they participate inpersonal therapy and carry out clinical workat the same time.Accessing therapy while training is hard –especially financially. This stress is likely toreduce the effectiveness of the therapy.

(Continued )

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Table 1. Continued.

Paper Method Participants Rationale – summary Critical concepts identified by the author/s

6. King (2011) Qualitative content analysisof interview transcripts

Eight therapists providing sessions topsychotherapy trainees

Therapists can only take clients to the depthsthey have been themselves.Personal therapy during training is a keyelement of eventually being a competentpractitioner.

Where students struggled with using therapyeffectively during training this may be anindication of their lack of suitability forpsychotherapy practice in the future.

7. Murphy (2005) Semi-structured groupinterview analysed usingGrounded Theory

Master of Counselling students Four key capacities are enhanced throughpersonal therapy: reflexivity, growth,authenticity and prolongation

8. Moller et al. (2009) Qualitative thematic analysis N = 37Eleven trainee Clinical Psychologists, 13Professional Doctorate in Counselling 13counselling Diploma trainees – allparticipated during first two weeks ofcommencing training

Having therapy is supportive and makescompleting training more likely. Seeingtherapy from the side of the client helpsempathy with the client experience. Usingpersonal therapy to promote mental health islikely to have a positive impact on clientoutcomes.

Students were unclear the rationale forneeding to undertake therapy.

9. Von Haenisch(2011)

IPA Six psychologists post training withbetween one and six years experience inthe field

Therapy is needed so that trainees can sort out‘troubled pasts’.

Participants in this study reported they didnot have traumatic early life experiencesand did not need therapy to address suchissues. Nonetheless they found it helpful.

10. Ivey (2014) Literature based discussionpaper

N/A Not having benefitted from being the recipientof therapeutic caring could hamperpsychotherapists’ ability to foster caringrelationships with their own clients.Balancing the ethical care of trainees withtheir rights needs to occur judiciously.

… given that psychotherapy is known toenhance the interpersonal competences andvirtues required to work therapeutically, thatit sensitises trainees to the experience of theclient role, that it fosters self-reflectivity,personal integration, and belief in thetherapeutic efficacy of the healingrelationship, there are good ethical groundsto insist that all trainee psychotherapistsexperience this singular process in the courseof their training.

Is it ethical to impose psychotherapy onsomeone who is not suffering, displays nopathological behaviour, and feels no needfor treatment?

Mandated personal psychotherapy may not beinherently unethical but imposing it with noalternative may be.

11. Rizq and Target(2008)

IPA analysis of interviews Nine qualified therapists who hadattended therapy

The intensity of attachment to the therapistdescribed by some participants equated to anexperience of parenting; others spoke aboutthe various ways in which the therapist’s

Participants believed strongly that therapyduring training should be obligatory butwere unable to identify the purposes oraims of this work.

(Continued )

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Table 1. Continued.

Paper Method Participants Rationale – summary Critical concepts identified by the author/s

willingness to engage in a ‘real’ relationshipsponsored in them a sense of emotionalauthenticity and a capacity to become morereal and present for their clients. For others,however, a concern with psychological safetyand boundaries emerged in order to contain,or even perhaps defend against, theperceived potential risks engendered by theintensity and authenticity of the therapeuticencounter.

12. Grimmer andTribe (2001)

Grounded theory Seven trainee therapists and sevenqualified therapists.

Personal therapy helps clients because thetherapist reduces the blind spots andlikelihood of unethical behaviour towards theclient

… is protective against the harmful belief thatthe therapist is superior to the client• Developing reflexivity• Validational experiences• Normalisation

Trainees can be preoccupied with their ownemotional turmoil if receiving therapyduring training.

Trainees can still gain from therapy even ifthey do not have a presenting problem.

13. Gold, Hilsenroth,Kuutmann, andOwen (2015)

Measures pre and postanalysed statistically.Interviews.

14 graduate/trainee clinicians Although other self-development processes canimprove insight and empathy personalpsychotherapy during training is the optimalchoice.

Findings suggest that how trainees rate theirpersonal therapy alliance impacts on theirclients rating of the outcomes of therapy

14. Holzman,Searight, andHughes (1996)

Survey 1018 graduate students of clinicalpsychology were approached tocomplete the survey – response rate50%

Personal therapy enhances empathy andreduces opportunity for harm.

Where therapy is optional students may fearseeking help as an indicator they are unfit topractice.

15. Strozier andStacey (2001)

Descriptive statistics 148 Master of SW faculty; 139 MSWstudents

Students who access personal therapyvoluntarily see it as foundational to beingable to practice effectively

Personal therapy allows students to deal withtheir current issues and provides increasedself-awareness

Faculty members reported lower value oftherapy than students. [NB this may bebecause they are aware of other ways self-development can be fostered].

16. Rizq (2011) Secondary analysis of formerstudy of 12 graduates

N/A Early attachment experience may be one of thefactors relevant to understanding how amandatory training therapy isperceived and experienced by trainees

Personal therapy for trainees is seen as a typeof indoctrinationResearch is sometimes in the style of ‘pressreports’

Quantitative research is inadequately detailedregarding experiences of trainees

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Table 1. Continued.

Paper Method Participants Rationale – summary Critical concepts identified by the author/s

Psychotherapy during training is necessarilyinsipid because the client conforms to the‘good child’ role

17. Wilson,Weatherhead,and Davies(2015)

Narrative analysis ofinterviews about experiencesof therapy during training

10 clinical psychologists – all female … outcomes from personal therapy can bebroadly grouped into: emotional support,enhanced self-awareness and professionaldevelopment.

… therapists who relate positive experiences oftheir therapy during training indicate itallowed them to become better therapists,and they are enthusiastic about similaropportunities being available to all traineeclinical psychologists

Personal therapy during training can be aburden – especially regards relationshipdifficulties, time and financial restraints, andpreoccupation with personal conflicts. [butit is not known how much of this is due tothe mandatory nature of the requirement].

18. Rizq and Target(2010b)

IPA study of responses/outcomes of the AdultAttachment Interview – plusinterview about therapyexperiences

12 BPS chartered psychologists Personal therapy during training improvesreflective functioning but secure attachmentis a requirement

Reflective functioning (the skill to bedeveloped through personal therapy intraining) is not always helpful because forsome candidates this can ‘trip over’ intoanxious/depressive ruminations

19. Chaturvedi(2013)

Literature review – criticalcommentary

N/A … being in the client’s chair is a humblingexperience that allows therapists to recognisepersonal issues

… studies relying on self-report offer anoverwhelmingly favourable view ofpersonal therapy.

…making therapy mandatory relies on anexclusivist position of therapy as the onlyacceptable means of change and growth.

… personal therapy is perceived, by manycourse leaders and therapists, to be avaluable element of therapy training,although there is no objective or empiricalevidence confirming the veracity of theseclaims.

… some practices may be rooted in traditionrather than supported by empiricalevidence

… students with legitimate concerns aboutthe value of therapy may be interpreted asresistive or needing a break from thetraining – trainees must either comply orrisk not qualifying

Note: IPA = Interpretive Phenomenological Analysis.

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Table 2. First order statements directly from rationales in the papers – meaning units derived from rationales within the papersidentified for analysis.

Personal psychotherapy during training helps the trainee to –o Experience what the client experienceso Learn techniques directly through modelling the therapist’s actions.o Have experiential evidence of effectiveness of therapyo Increase empathy based on experiencing the client roleo Increase their self-awarenesso Reduce stresso Be encouraged to engage in personal growth and developmento Understand how personal issues impact on practiceo Experience what it is like to be a cliento Know one’s boundarieso Experience first-hand the intense self-experiences that can occur in personal psychotherapyo Develop personal reflexivityo Develop capacity for insighto Increase acceptance of the self.o Manage difficult aspects of their trainingo Understand the processes and dynamics of psychotherapyo Enhance experiences of transferenceo Enhance experiences of interpretationo Enhance experiences of terminationo Enhance experience of therapy techniqueso Enhance understanding of client roleo Make major gains, both with their clinical work and in their personal liveso Understand that therapists can only take clients to the depths they have been themselveso Engage a key element of eventually being a competent practitionero Enhance reflexivityo Enhance growtho Enhance authenticityo Enhance prolongation (staying the course to experience the benefits)o Experience therapeutic supporto Be more likely to complete the trainingo Enhance empathy with the client experienceo Enhance personal mental health which is likely to have a positive impact on client outcomes.o Sort out any aspects of ‘troubled pasts’o Foster caring relationships with their own clients.o Enhance their interpersonal competences and virtues required to work therapeuticallyo Be sensitised to the experience of the client roleo Foster their self-reflectivityo Foster their personal integrationo Enhance their belief in the therapeutic efficacy of the healing relationshipo Undertake an ethical requirement of training and future practiceo Be more in tune with their own experience as a client in therapyo To know that having therapy can be beneficial for everyone therefore students will benefito Have the experience of being parented effectivelyo Have an experience of the ‘real’ relationship in therapy which sponsors emotional authenticity and a capacity to become more

real and present for their clients.o Reduce blind spotso Reduce likelihood of unethical behaviour towards the cliento Be protected against the harmful belief that the therapist is superior to the cliento Develop empathyo Enhance empathyo Reduce opportunity for harm.o Deal with their current issueso To develop increased self-awarenesso Receive emotional supporto Enhance self-awarenesso Contribute to their professional development.o Have a humbling experienceo Enhance recognition of personal issues

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commonalities and tensions. This process occurred throughout the synthesis. However, a commonarea of disagreement across different papers concerned the reasons students have difficulties withattendance at personal therapy during training. Therefore this was the focus of a small stand-alone refutational synthesis.

The explanations provided in the studies as to why students struggle with therapy can be simplis-tically described as placing students into a win–lose scenario. The win can include the positive helpthey gain from personal therapy with the loss that it may, for example, clarify and exacerbate thesource of relationship tensions. Additionally they may win the course requirements procedure bytaking the good child stance in the therapy and therefore lose the benefits of an in-depth interper-sonal process.

The outcomes of therapy engagement may not be useful for their completion of their training. Forexample, students who raise concerns about the value of personal therapy may be perceived asunsuitable for therapy practice. They can risk not qualifying. However, the critical capacities thetrainee demonstrates by being able to perceive difficulties in a bigger picture way could be a positiveindicator of a counsellor or psychotherapist. Perceiving the difficulties of the client through a moreholistic and ecological lens can be an advantage to supporting positive change for a therapy client.

The main reasons given as why students have difficulties attending personal therapy were eitherlocated in the processes and outcomes of therapy, and/or located in the student’s circumstances. Theoutcomes of therapy that were seen to disrupt trainee progress included, (1) preoccupation with self,making the student less available for reflection on client distress, (2) the risk of anxious/depressiverumination – a negative extension of reflective function, (3) difficulties can indicate whether or notstudent is suitable as a future therapy practitioner. The personal circumstances indicated as proble-matic for the trainee included, (1) financial difficulties, (2) crossover between the training period andpersonal developmental milestones and (3) existing intimate relationship stress.

Table 3. The rationale for (mandated) personal psychotherapy during training.

Personal psychotherapy during training is required because it can:

Enhance the trainee’s capacity for empathy towards the clientexperience what the client experiences – what it is like to be a client – Enhancing understanding of client role – it sensitisestrainees to the experience of the client role – be more in tune with their own experience as a client in therapy

Enhance the trainee’s knowledge of techniques and capacities for use in practicelearn techniques directly through modelling the therapist’s actions – enhance experiences of transference – enhanceexperiences of interpretation – enhance experiences of termination – enhance experience of therapy techniques – knowingone’s boundaries – understanding of the processes and dynamics of psychotherapy – enhances the interpersonal competencesand virtues required to work therapeutically – the ‘real’ relationship in therapy sponsors emotional authenticity and a capacity tobecome more real and present for their clients.

Reduce the likelihood of future harm towards clientsthe therapist reduces their blind spots – reduces likelihood of unethical behaviour towards the client – reduces opportunity forharm – Therapists can only take clients to the depths they have been themselves – helps trainee ability to foster caringrelationships with their clients – is protective against the harmful belief that the therapist is superior to the client

Contribute to the trainee’s personal growthincreased self-awareness – reduced stress – encourage personal growth and development – personal reflexivity – insight –acceptance of the self – helps with difficult aspects of their training – Enhance reflexivity – Enhance growth – enhanceauthenticity – supportive –makes completing the training more likely – helps trainees sort out ‘troubled pasts’ – Using personaltherapy to promote personal mental health is likely to have a positive impact on client outcomes – fosters self-reflectivity –fosters personal integration – the experience of parenting through the relationship with the therapist – Provides a way to dealwith their current issues – provides increased self-awareness – emotional support – enhanced self-awareness – is a humblingexperience – enhances recognition of personal issues

Help the trainee gain deeper insight into therapeutic processesTrainee gains experiential evidence of effectiveness of therapy – how personal issues impact on practice – the intense self-experiences that can occur in personal psychotherapy – enhance prolongation (staying the course to experience the benefits)

Afford wider implications and benefitsIs an ethical requirement – promotes belief in the therapeutic efficacy of the healing relationship – having therapy can bebeneficial for everyone therefore students will benefit – is part of professional development

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Further critical reflection fundamental to the CIS process was then undertaken by (a) contemplat-ing all statements generated through the synthesis, (b) writing out responses to the statements and(c) seeking further literature relevant to personal psychotherapy during training. This resulted in afinal synthesising argument presented and discussed below.

Discussion

The current rationale for personal psychotherapy as part of therapy training is summarised in the fol-lowing critical synthesising argument:

In spite of the minimal evidence to show the benefits to the trainee, or their future competence in practice, ofengaging personal psychotherapy during training, there are multiple published reports to show that evenwhen trainees do not appreciate personal psychotherapy at the time of undertaking it they later reflect back

Table 4. First order statements raising concerns about the value of personal psychotherapy for therapy trainees.

Personal psychotherapy during training is problematic because –

It is disputed whether personal psychotherapy is warranted for well, untroubled traineesParticipants in this study reported they did not have traumatic early life experiences and did not need therapy to address suchissues. Nonetheless they found it helpful.Is it ethical to impose psychotherapy on someone who is not suffering, displays no pathological behaviour, and feels no need fortreatment?Trainees can still gain from therapy even if they do not have a presenting problem.

Other self-development pathways apart from mandated personal psychotherapy should be consideredPrior experience may be adequateMandated personal psychotherapy may not be inherently unethical but imposing it with no alternative may be.Faculty members reported lower value of therapy than students. [NB this may be because they are aware of other ways self-development can be fostered].…making therapy mandatory relies on an exclusivist position of therapy as the only acceptable means of change and growth.Psychotherapy during training is necessarily insipid because the client conforms to the good child role

Although there is some evidence for the benefit of personal psychotherapy, claims for the benefits of PP over-reach the existing evidenceHow trainees rate their personal therapy alliance impacts on their clients rating of the outcomes of therapy… studies relying on self-report offer an overwhelmingly favourable view of personal therapy.… personal therapy is perceived, by many course leaders and therapists, to be a valuable element of therapy training, althoughthere is no objective or empirical evidence confirming the veracity of these claims.… assumption that therapists’ self-reported improved skills and well-being impact positively on clients… there is only indirectevidence of increased empathy and therapist warmth to support this suggestion.… some practices may be rooted in tradition rather than supported by empirical evidenceResearch is sometimes in the style of ‘press reports’Quantitative research is inadequately detailed re-experiences of trainees

Trainees’ resistance to engaging therapy is not dealt with optimallyTrainees start out with the idea that having to attend therapy is a personal attack… students with legitimate concerns about the value of therapy may be interpreted as resistive or needing a break from thetraining - trainees must either comply or risk not qualifyingWhere therapy is optional students may fear seeking help as an indicator they are unfit to practice.

Personal psychotherapy during training is hard and expensive, and can disrupt effective work with clients… trainee therapists’ skills become negatively affected when they participate in personal therapy and carry out clinical work atthe same time.Trainees can be preoccupied with their own emotional turmoil if receiving therapy during training.Normal professional development crises can be aggravatedAccessing therapy while training is hard – especially financially. This stress is likely to reduce the effectiveness of the therapy.Where students struggled with using therapy effectively during training this may be an indication of their lack of suitability forpsychotherapy practice in the future.Personal therapy during training can be a burden – especially regards relationship difficulties, time and financial restraints, andpreoccupation with personal conflicts. [but it is not known how much of this is due to the mandatory nature of the requirement].

The rationale for personal psychotherapy is not adequately clearStudents were unclear the rationale for needing to undertake therapy.Participants believed strongly that therapy during training should be obligatory but were unable to identify the purposes or aimsof this work.Personal therapy for trainees is seen as a type of indoctrination

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on it as key to their growth and eventual competence in the field. There are strongly held beliefs that underpinthe use of personal psychotherapy as an essential self-development process during training. These include: thereduction of harm to the client, the personal growth of the trainee, and the development of new insights andskills needed to be an effective therapist in the future. The strongest rationales about the outcomes of personalpsychotherapy is that the process will assist the trainee to have more empathy with the client, will challenge andobviate any stigma the trainee holds about those who attend therapy, and will reduce the risk of harm throughthe trainee having lived experience of the vulnerability of being in client role. However, these beliefs must bemitigated with the caveat that there is also a range of opinion, again without any substantive evidence, whichexpresses concern about the value of exploring one’s own issues deeply while providing this same deep experi-ence for someone else, and the difficulties in being able to provide support to highly distressed people while(possibly) experiencing distress from one’s own issues being explored in personal psychotherapy.

Further additional concerns raised through undertaking this review is that students may not haveadequate knowledge of therapy and the therapy role to know when boundary violations are occur-ring. Students are at risk of being traumatised in therapy through empathic mis-steps that the thera-pist is not adequately skilled to identify and address. The CIS process exposed a number of identifiedrisks that need to be managed by the course, the profession and the student. These are summarisedas follows:

If there are issues that arise for the student during personal psychotherapy that are difficult for them to manage,or actually disrupt the training process for them, the only options are to either continue attending sessions, or toleave and risk not completing the qualification. Consideration of options for the student to complete a supportiveself-development process by another means should be engaged.

There could be value in expecting students to have engaged in personal psychotherapy prior toenrolling to study to become a therapist. If they would like to engage in further personal therapyduring their training that would be entirely their own decision and responsibility. However, cautionsmust be taken not to create a situation in which future applicants feel compelled to have therapywhen they have no need of it, or undertake the pre-course requirement with a minimal commitmentto opening their lives to change. The usefulness of personal therapy during training can be impactedby multiple aspects of the student experience. As Malikiosi-Loizos (2013) has indicated,

… training… is a mentally and emotionally charged activity: students are trying to master new skills, establish aprofessional identity and a sense of self–efficacy as a therapist and deal with the personal issues that arise fromthe experiential nature of the training itself.

Limitations

Interpretations of this research must be applied with caution. This was a secondary analysis of exist-ing research studies. The studies were heterogeneous. They varied in their methodology and trainingorientation. Some studies included surveys either undertaken during and following training. Studieswhich reported the experiences of students varied in whether the students were at entry level in theirfirst counselling training, or were taking a higher degree such as the Clinical Doctorate in Psychology,or Master of Clinical Social Work. Some studies recruited students from different training programmeswith differing therapeutic practice orientations.

Meta-synthesis is not intended to achieve consensus. Rather, the interpretations of a researcherapplying a critical interpretive process are reported. Although the aim of congruence has beenmet, there may be some idiosyncratic aspects of the findings that belong to the author’s unique per-spective based on reflections on her experiences of providing training.

Conclusion and future directions

The rationale for attending personal psychotherapy during training is strong, the risks challengingand the evidence for its immediate and long term benefit weak. There is more to be done to evaluatethe claims underpinning the rationale for personal psychotherapy during training, whether it is man-dated or recommended. This further research should:

528 J. EDWARDS

1. Create comparator studies between courses to evaluate outcomes for students.2. Engage in longitudinal and/or post-hoc research to examine outcomes of trainees who have posi-

tive experiences of their in-training psychotherapy, and those who don’t.3. Compare personal therapy with other training dimensions that promote reflective function.

Additionally, course teams and professional associations should engage in conference presenta-tions and discussion groups – perhaps also online – that can allow a wider discussion of the issuesunderpinning personal development during training.

It is noteworthy that there is evidence that mentalisation training significantly enhances traineetherapists’ capacity to engage reflective function (Ensink et al., 2013). Further understanding ofhow personal therapy achieves gains for the trainee, especially with regards the essential skill ofreflective function is needed. The means by which this knowledge could be acquired in alternativeways requires further consideration.

Course teams need to further reflect upon and document their methods of supporting and advis-ing trainees who attend psychotherapy. Students need clear information from their course prospec-tus and from the professional association as to what they should ideally expect from attendance attherapy, including any potential risks. Further research will help course teams and professional associ-ations to carefully deliberate the costs and gains of personal therapy as part of training.

Disclosure statement

No potential conflict of interest was reported by the author.

Notes on contributor

Jane Edwards is an Associate Professor in Mental Health at Deakin University in Victoria, Australia. She is a qualified crea-tive arts therapist with expertise in child and family mental health.

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